Provider Demographics
NPI:1962790006
Name:MIRON CARCAMO, LUIS PEDRO
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:PEDRO
Last Name:MIRON CARCAMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S PROSPECT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7054
Mailing Address - Country:US
Mailing Address - Phone:217-305-7980
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1701 S PROSPECT AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7054
Practice Address - Country:US
Practice Address - Phone:217-305-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE604486541223G0001X
IL019030115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044967Medicaid